Incorporating shared decision making in mental health care requires translating knowledge from implementation science

M. Slade1 provides a broad overview of the literature on shared decision making (SDM) with a focus on mental health care. The overview is timely and pertinent, as SDM is considered a central component of the widely accepted recovery model of mental health services2. We are encouraged by Slade's focus on implementation, which is the current challenge facing SDM practice across all settings and countries.

Slade highlights significant challenges to decision aid uptake, including quality control and the overwhelming number of those aids. The movement toward quality control of decision aids is over ten years old. The International Patient Decision Aids Standards Collaboration (http://ipdas.ohri.ca) has provided criteria to judge the quality of patient decision aids. Certification is also underway and has the potential to improve the quality of the growing number of those aids.

However, we agree that the current model of decision aid development and maintenance is unsustainable. The use of technology is being harnessed to address this challenge. For example, the SHARing Evidence to Inform Treatment decisions (SHARE‐IT) project is an initiative designed to automate decision aid production based on guideline updates3.

While decision aids are useful adjuncts to SDM, it is important to clarify that the practice of SDM does not require a decision aid. Informing patients of their options, eliciting their preferences and integrating these patient preferences into the health care decision is a practice that requires communication skills, not just tools. Only a clinician who has the necessary communication skills can appropriately use a decision aid during the consultation. The use of decision aids can indeed promote the engagement of patients in the decision making process, but there are also other ways of fostering SDM, including patient‐mediated interventions that prompt patients to ask questions4.

We agree with Slade's second challenge that SDM implementation endeavors could potentially be more successful if better integrated into other innovations in mental health care. This argument is especially compelling from a clinician's perspective. By branding SDM as the most important singular new intervention that clinicians must adhere to in their portfolio of skills and interventions, we undermine its potential and may cause resistance. More work is needed to integrate SDM with other health care innovations in particular fields of health care. Thus, the mental health field has the potential to take the lead, for example, through the integration of SDM and advance directives and joint crisis plans5.

Slade highlights the important ethical tension between beneficence and patient autonomy to make decisions. An over‐emphasis on beneficence‐focused treatment at the expense of patient autonomy can result in treatment decisions that represent the clinician's values imposed on the patient. This is particularly concerning in mental health care, where the effectiveness of treatments is often overstated, despite only modest gains and significant potential side effects.

As Slade indicates, the question most often raised in mental health care relates to an individual's decision making capacity. While individuals with mental illness may have impaired cognitive abilities, most desire and have the capacity to be involved in treatment decision making, including those with severe conditions such as schizophrenia and major depression6. Similar to patients with other cognitive disabilities, strategies are available to increase participation in decision making among individuals with severe mental illness, such as the use of multiple display formats when communicating treatment options and risks.

Of course, these individuals are not always capable of becoming involved in a decision making process; this ability may vary over the course of their illness. In such cases, joint crisis plans may be useful. For example, when a patient's decision making capacity is reduced, a clinician or family member can draw on the patient's stated preferences that were gathered when the patient was capable of making a decision. Such plans could be beneficial in institutional settings where patient autonomy is even more restricted.

Nevertheless, research has shown that most people diagnosed with a mental illness have a similar level of decision making capacity as a healthy comparison group from the general population6. Increased awareness of this ability would be an important step toward increasing patient engagement in SDM.

This appeal for reducing the stigma towards mentally ill patients by not denying them their decision making capacities is related to the prominent and broader call for a culture change in health care practice. In order to achieve this culture change in the clinical world and move away from paternalism, we need to do more than just change attitudes and norms of individual health care professionals. Change is needed at all levels, from individual to organizational and institutional.

Slade correctly points out that when considering how to transform mental health care systems – both regarding SDM and other possible upcoming changes – it could be helpful to “use language and constructs from other sectors to inform this transformation”1. When discussing the implementation of SDM, whether in mental health care or in other clinical areas, we should carefully consider translating knowledge from the field of implementation science to influence clinical care. For successful implementation we need to take a range of basic sciences (e.g., behavioral science, psychology, communication, economics) into account; thus, social marketing can only be one piece of the jigsaw.

We recommend the Consolidated Framework for Implementation Research7 to develop a theoretically based implementation strategy. This stresses the need to foster implementation at different levels (e.g., individual, organizational, policy) and describes social marketing as one among a range of other activities (e.g., education, role modeling, training) to engage stakeholders at the individual level. Another seminal model is the Behavior Change Wheel8, which can be used to design behavior change interventions to foster routine implementation of SDM.

In summary, we applaud Slade for his effort to push forward the SDM agenda in the mental health field. We agree with his conclusion that implementation challenges are the key concern. Social marketing and insights from the hospitality industry are unique and helpful, but they must be combined with implementation science to effectively amplify the voice of those with mental illness in making treatment decisions through an SDM process.

Isabelle Scholl1, Paul J. Barr2
1Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 2Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA